Duodenal stricture secondary to IgG4-related chronic sclerosing duodenitis-A case report with review of the literature.

Key Clinical Message: This case highlights the importance of a definite diagnosis of an IgG4-related chronic sclerosing duodenitis based on histological and radiological findings to rule out any malignancy in the mass. While dealing with patients having concentric duodenal thickening resulting in stricture formation, one should think of inflammatory etiology as well. IgG4-related disease is one of these inflammatory disorders where we see soft tissue thickening without a large mass or any associated lymphadenopathy as in our case. Abstract: Immunoglobulin G4-related disease (IgG4-RD) is distinguished as an infiltration of IgG-4-positive plasmacytes involving inflammatory lesions across multiple organs which is accompanied by raised IgG4 levels in the serum. Several inflammatory disorders are recognized as part of the IgG4-RD family based on shared histopathological features, which include Mikulicz's disease, chronic sclerosing sialadenitis, or Riedel's thyroiditis. Our case highlights a distinctive presentation of IgG4-related diseases; a 58-year-old man presenting with duodenal stricture highly suspicious of a duodenal mass/ampullary mass later found to be due to IgG4-related sclerosing duodenitis with negative malignancy on biopsy. We present the diagnostic challenges faced and relevant findings noted.

Transforming surgical landscapes: obstacles in the integration of robotic surgery in Pakistan -is cost the only limiting factor?

The advantages of Robotic Assisted Surgery (RAS) over laparoscopic surgery encompass enhanced precision, improved ergonomics, shorter learning curves, versatility in complex procedures, and the potential for remote surgery. These benefits contribute to improved patient outcomes which have led to a paradigm shift in robotic surgery worldwide and it is now being hailed as the future of surgery. Robotic surgery was introduced in Pakistan in 2011, but widespread adoption has been limited. The future of RAS in Pakistan demands a strategic and comprehensive plan due to the substantial investment in installation and maintenance costs. Considering Pakistan's status as a low to middle-income country, a well-designed economic model compatible with the existing health system is imperative. The debate over high investments in robotic surgery amid unmet basic surgical needs underscores the complex dynamics of healthcare challenges in the country. In this review, we discuss the potential benefits of robotics over other surgical techniques, where robotic surgery stands in Pakistan and the possible hurdles and barriers limiting its use along with solutions to overcome this in the future.

Journey of medication reconciliation compliance in a lower middle-income country: a retrospective chart review.

OBJECTIVE: There were three main objectives of the study: to determine the overall compliance of medication reconciliation over 4 years in a tertiary care hospital, to compare the medication reconciliation compliance between paper entry (initial assessment forms) and computerised physician order entry (CPOE), and to identify the discrepancies between the medication history taken by the physician at the time of admission and those collected by the pharmacist within 24 hours of admission. METHODS: This study was conducted at a tertiary care hospital in a lower middle-income country. Data were gathered from two different sources. The first source involved retrospective data obtained from the Quality and Patient Safety Department (QPSD) of the hospital, consisting of records from 8776 patients between 2018 and 2021. The second data source was also retrospective from a quality project initiated by pharmacists at the hospital. Pharmacists collected data from 1105 patients between 2020 and 2021, specifically focusing on medication history and identifying any discrepancies compared with the history documented by physicians. The collected data were then analysed using SPSS V.26. RESULTS: The QPSD noted an improvement in physician-led medication reconciliation, with a rise from 32.7% in 2018 to 69.4% in 2021 in CPOE. However, pharmacist-led medication reconciliation identified a 25.4% (n=281/1105) overall discrepancy in the medication history of patients admitted from 2020 to 2021, mainly due to incomplete medication records in the initial assessment forms and CPOE. Physicians missed critical drugs in 4.9% of records; pharmacists identified and updated them. CONCLUSION: In a lower middle-income nation where hiring pharmacists to conduct medication reconciliation would be an additional cost burden for hospitals, encouraging physicians to record medication history more precisely would be a more workable method. However, in situations where cost is not an issue, it is recommended to adopt evidence-based practices, such as integrating clinical pharmacists to lead medication reconciliation, which is the gold standard worldwide.

Orthopaedic Surgery Complications at a Tertiary Care Hospital in a Low- and Middle-Income Country: A National Surgical Quality Improvement Project Analysis.

BACKGROUND: Through a comparison of orthopaedic surgical procedures performed at a tertiary care hospital in Pakistan with other participating hospitals of National Surgical Quality Improvement Project (NSQIP), we aim to identify the areas of orthopaedic surgical care at our center that need improvement and also those which are at par with international standards. METHODS: The study analyses orthopaedic surgeries at a tertiary care hospital in Pakistan using NSQIP registry to compare complication rates with other American College of Surgeons-NSQIP participant hospitals. Two reviewers collect data in different days every 8 days to reduce bias, and the results are reported in odds ratios using quarterly reports. This study included 584 eligible orthopaedic cases performed in 2021. Yearly institutional reports with odds ratios were also used to identify areas needing improvement and to implement changes to improve orthopaedic surgical outcomes at said institute. RESULTS: The quarterly reports suggest a relatively higher OR for certain indicators such as cardiac events, surgical site infection, mortality, and morbidity throughout. The renal failure rate was very high in the third and fourth quarters with odds ratios of 4.57 and 10.31, respectively. However, the official NSQIP annual institutional report for 2021 identified sepsis, surgical site infections, and cardiac complications as areas 'needing improvement'. It also indicated that the hospital performed exemplarily when it came to venous thromboembolism (VTE). As for the rest of the indicators, the hospital fell in the 'as expected' category of the NSQIP standards. CONCLUSION: This initial report helps the hospital's orthopaedic department in recognizing areas for improvement and making system-level changes to improve patient outcomes. The implementation of these interventions has yielded favorable outcomes, as evidenced by the findings in the NSQIP yearly report for 2022. Reinforcements and measures are needed to be taken to reduce the adverse events even further and to improve the patient outcomes and quality.

Return to Work in Patients With Unilateral Inguinal Hernia Surgery: A Comparative Study Between Laparoscopic Transabdominal Preperitoneal Approach and Lichtenstein Tension-Free Mesh Repair.

Objective The objective of this prospective cohort study was to compare the time to return to work between patients who underwent laparoscopic transabdominal preperitoneal (TAPP) hernia repair and those who underwent Lichtenstein tension-free hernia repair with mesh for unilateral inguinal hernia. Methodology Patients were registered for unilateral inguinal hernia review at Aga Khan University Hospital, Karachi, Pakistan, from May 2016 to April 2017 and followed till April 2020. All patients aged 16-65 planned for unilateral transabdominal preperitoneal hernia repair or Lichtenstein tension-free hernia mesh repair were included. Patients with bilateral inguinal hernia repair, limited activity, or above retirement age were excluded. A non-probability consecutive sampling technique was implemented, and patients were divided into two cohort groups: Group A underwent laparoscopic transabdominal preperitoneal hernia repair, while Group B underwent Lichtenstein tension-free mesh repair. Patients were followed up at one week to inquire about the resumption of activities and then at one and three years for recurrence. Results Sixty-four patients met the inclusion criteria; three patients opted out of research, and 61 patients agreed to participate; one patient was excluded due to the conversion of the procedure. The remaining 30 in Group A and 30 in Group B were followed for the study period. The mean time to return to work in Group A was 5.33 ± 4.46 days; in Group B, it was 6.83 ± 4.58 days, with a p-value of 0.657. One recurrence was observed at three years in Group A. Conclusion Although the time to return to work at our hospital was slightly shorter in laparoscopic hernia repair than in the open technique, the results were not statistically significant. In addition, there was no significant difference in hernia recurrence at the one-year follow-up between laparoscopic transabdominal preperitoneal hernia repair and Lichtenstein tension-free hernia mesh repair for unilateral inguinal hernia.

Association of Metabolic Syndrome with Stroke, Myocardial Infarction, and Other Postoperative Complications Following Carotid Endarterectomy: A Multicenter, Retrospective Cohort Study.

BACKGROUND: Metabolic syndrome (MetS) is a constellation of hypertension, insulin resistance, obesity, and dyslipidemia and is known to increase the risk of postoperative morbidity. This study aimed to assess the impact of MetS on stroke, myocardial infarction, mortality, and other complications following carotid endarterectomy (CEA). METHODS: We analyzed data from the National Surgical Quality Improvement Program. Patients undergoing elective CEA between 2011 and 2020 were included. Patients with American Society of Anesthesiologists status 5, preoperative length of stay (LOS) > 1 day, ventilator dependence, admission from nonhome location, and ipsilateral internal carotid artery stenosis of < 50% or 100% were excluded. A composite cardiovascular outcome for postoperative stroke, myocardial infarction, and mortality was generated. Multivariable binary logistic regression analyses were used to assess the association of MetS with the composite outcome and other perioperative complications. RESULTS: We included 25,226 patients (3,613, 14.3% with MetS). MetS was associated with postoperative stroke, unplanned readmission, and prolonged LOS on bivariate analysis. On multivariable analysis, MetS was significantly associated with the composite cardiovascular outcome (1.320 [1.061-1.642]), stroke (1.387 [1.039-1.852]), unplanned readmission (1.399 [1.210-1.619]), and prolonged LOS (1.378 [1.024-1.853]). Other clinico-demographic factors associated with the cardiovascular outcome included Black race, smoking status, anemia, leukocytosis, physiologic risk factors, symptomatic disease, preoperative beta-blocker use, and operative time ≥ 150 min. CONCLUSIONS: MetS is associated with cardiovascular complications, stroke, prolonged LOS, and unplanned readmissions following CEA. Surgeons should provide optimized care to this high-risk population and strive to reduce operative durations.

Measuring the patient safety culture at a tertiary care hospital in Pakistan using the Hospital Survey on Patient Safety Culture (HSOPSC).

BACKGROUND: Patient safety is a top priority for many healthcare organisations worldwide. However, most of the initiatives aimed at the measurement and improvement of patient safety culture have been undertaken in developed countries. The purpose of this study was to measure the patient safety culture at a tertiary care hospital in Pakistan using the Hospital Survey on Patient Safety Culture (HSOPSC). METHODS: The HSOPSC was used to measure the patient safety culture across 12 dimensions at Aga Khan University Hospital, Karachi. 2,959 individuals, who had been working at the hospital, were administered the HSOPSC in paper form between June and September 2019. RESULTS: The response rate of the survey was 50%. In the past 12 months, 979 respondents (33.1%) had submitted at least one event report. Results showed that the personnel viewed the patient safety culture at their hospital favourably. Overall, respondents scored highest in the following dimensions: 'feedback and communication on error' (91%), 'organisational learning and continuous improvement' (85%), 'teamwork within units' (83%), 'teamwork across units' (76%). The dimensions with the lowest positive per cent scores included 'staffing' (40%) and 'non-punitive response to error' (41%). Only the reliability of the 'handoffs and transitions', 'frequency of events reported', 'organisational learning' and 'teamwork within units' was higher than Cronbach's alpha of 0.7. Upon regression analysis of positive responses, physicians and nurses were found to have responded less favourably than the remaining professional groups for most dimensions. CONCLUSION: The measurement of safety culture is both feasible and informative in developing countries and could be broadly implemented to inform patient safety efforts. Current data suggest that it compares favourably with benchmarks from hospitals in the USA. Like the USA, high staff workload is a significant safety concern among staff. This study lays the foundation for further context-specific research on patient safety culture in developing countries.

Collision versus loss-of-control motorcycle accidents: Comparing injuries and outcomes.

OBJECTIVE: Motorcycles are a common mode of transport, especially in low-middle-income countries like Pakistan. The pattern and severity of injuries in motorcycle trauma depends on the mechanism of accident, which may be classified as collision accidents (CAs) or loss-of-control accidents (LOCAs). In this study, we aimed to investigate patterns of trauma due to motorcycle CAs and LOCAs, with a focus on injuries, management, complications, and outcomes. METHODS: A retrospective cohort study was conducted at the Aga Khan University Hospital (AKUH), Pakistan (a level 1 trauma facility), enrolling all patients presenting with motorcycle trauma between January 2018 and March 2019. RESULTS: The most common sites of major injury were the lower limb (40.9%), head and neck (38.1%), and upper limb (27.5%). A significantly higher percentage of CA victims had head and neck injuries (43.4% vs. 30.5%), abdominal injuries (5.5% vs. 1.1%), pelvic fracture (5.9% vs. 0%), and polytrauma (22.8% vs. 11.1%). Compared to LOCA victims, CA victims had a significantly higher incidence of acute kidney injury (AKI; 25.7% vs. 15.8%; P < .011), longer hospital lengths of stay (LOSs; 3 [2-6] days vs. 2.5 [2-4] days; P = .019), and long-term disability (P = .002). When adjusted for age and gender on multivariable logistic regression with mechanism of accident as the dependent variable, CA was significantly associated with male gender (odds ratio [OR] = 2.045, 95% confidence interval [CI] [1.038-4.026]), abdominal injury (OR = 5.748, 95% CI [1.285-25.702]), head and neck injury (OR = 1.492, 95% CI [1.007-2.211]), polytrauma (OR = 2.368, 95% CI [1.383-4.055]), AKI (OR = 1.937, 95% CI [1.183-3.171]), and LOS (OR = 1.041, 95% CI [1.004-1.079]). CONCLUSIONS: Though both motorcycle CAs and LOCAs stress trauma systems in developing countries, the dynamics of CAs mean that they result in worse injuries and outcomes. Specific measures to reduce CAs and LOCAs are urgently indicated in developing countries to reduce the burden of morbidity and mortality of motorcycle accidents.

A Comprehensive Assessment of Blood Transfusions in Elective Thyroidectomy Based on 180,483 Patients.

OBJECTIVES: To assess the incidence, risk factors, and complications of blood transfusions (BTs) in elective thyroidectomy patients. METHODS: A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program. Adult patients who underwent elective thyroidectomy from 2005 to 2019 were divided into two cohorts based on whether they received BT or not. Multivariable binary logistic regression models were used to identify risk factors of BT and its impact on postoperative complications. RESULTS: Of 180,483 patients, 0.13% received BT. Risk factors for BT included underweight body mass index (BMI) (adjusted odds ratio [OR] 3.179, 95% confidence interval [CI] 1.444-6.996), bleeding disorders (OR 2.121, 95% CI 1.149-3.913), anemia (OR 4.730, 95% CI 3.472-6.445), preoperative transfusion (OR 7.230, 95% CI 1.454-35.946), American Society of Anesthesiology physical statuses 3-5 (OR 3.103, 95% CI 2.143-4.492), operative time >150 min (OR 4.390, 95% CI 1.996-9.654), and inpatient thyroidectomy (OR 5.791, 95% CI 3.816-8.787). In addition, transfusion was independently associated with any postoperative complication, non-infectious, cardiac, pulmonary, renal, vascular, or infectious complications, surgical site infection, sepsis, septic shock, wound disruption, pneumonia, unplanned reoperation, prolonged length of stay, and mortality. CONCLUSION: Recognition of risk factors of BT is imperative to identify at-risk patients and reduce transfusions by controlling modifiable risk factors such as anemia, operative time, and BMI. In cases where transfusions are still indicated, surgeons should optimize care to prevent or adequately manage transfusion-associated complications. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:2078-2084, 2022.

In a digitally connected world through Likes, Hashtags and Followers - Advancing surgical research through a social media: A narrative review.

In this era of modern information technology, the world is now digitally connected through various platforms on social media, which has changed the way medical professionals work, communicate and learn. The use of social media in surgery is expanding, and it is now becoming an essential tool for surgical training, research and networking. Articles, journal clubs and surgical conferences are within reach of everyone regardless of geographical location worldwide. Electronic publications have now resoundingly replaced printed editions of journals. Collaborative research through social media platforms helps collect diverse data, enhancing the research's global generalisability. The current narrative review was planned to discuss the importance of social media in advancing surgical research and the use of different social media applications in the context of promoting and disseminating surgical research alongside its evolving ethical challenges.

Surgical Management During the COVID-19 Era at a Private Tertiary Care Hospital of Karachi, Pakistan: A Cross-Sectional Study.

Background The coronavirus disease 2019 (COVID-19), declared a pandemic in March 2020, has affected the entire healthcare system, including the surgical practice. Guidelines for the management of surgical patients during this COVID-19 era need to be established to provide timely yet safe surgical care. In this study, we aimed to evaluate the outcomes of the COVID-19 testing algorithm established for surgery patients presenting to a tertiary care hospital in Karachi, Pakistan, and to compare the outcomes among patients who underwent elective versus emergency surgery. Methodology This is a cross-sectional study conducted at a tertiary care hospital in Pakistan to apply and assess the outcomes of the COVID-19 testing algorithm established for patients presenting for surgery. We included all patients who underwent any surgery from May to October 2020. The total sample size was 6,846. The data were analyzed using SPSS version 23 (IBM Corp., Armonk, NY, USA). The categorical variables were assessed using the chi-square or Fisher's exact test. A p-value of <0.05 was considered significant. Results A total of 6,846 surgeries were performed from May 1 to October 31, 2020. In total, 74% of the surgeries were elective procedures. We observed that a significantly higher proportion of emergency surgery patients tested positive for COVID-19 (4.2%) compared to elective surgery patients (25/5,063, 0.5%). A higher proportion of surgeries were performed in September (1,437, 21%) and October (1,445, 21%) while the lowest number of surgeries were performed in May (625, 9.1%). From week one to week five, a higher proportion of emergency surgeries were performed (32%) compared to elective surgeries (25%). Only 1.9% of the patients who were undergoing surgery were COVID-19 positive, with the highest number of COVID-19 cases presenting in June. Overall, 74 (4.2%) of the COVID-19-positive patients underwent emergency surgeries. Conclusions The timely establishment of well-defined guidelines for surgical management during the pandemic allowed us to provide timely and effective surgical care to patients with the priority of minimizing the spread of COVID-19 and preventing unnecessary deferral of surgeries.

Changes in patterns and outcomes of trauma patients after betterment in law and order situation of the city.

OBJECTIVE: To assess the impact of the law and order situation of a city on the pattern of traumatic injuries and the overall outcomes of trauma victims. METHODS: The retrospective study of prospective trauma surgery data was done at Aga Khan University Hospital, Karachi, and comprised data of patients with torso injuries before the improvement of law and order situation from January 2012 to March 2013 in Group A, and of those with similar injuries after the law and order situation improved in the city from January 2018 to March 2019 in Group B. The required data was collected by a single researcher using a predesigned questionnaire. Inter-group comparison was done to see the difference in patterns of injuries and outcomes. Data were analysed using SPSS 22. RESULTS: Of the 676 cases reviewed, Group A had 416(61.5%); 363(87%) males and 53(13%) females with overall mean age of 37±13 years. Group B had 260(38.5%); 219(84%) males and 41(16%) females with overall mean age of 36±13 years (p>0.05). Penetrating trauma alone or combined with blunt force was the most common mechanism in Group A i.e. 245 (59%) patients, while in group B blunt trauma was the commonest cause 209 (80.4%) patients. There was an overall 156 (37.5%) cases reduction in torso trauma cases. Mortality in Group A was 22(5.3%) and in Group B it was 7(2.7%). CONCLUSIONS: With the improvement in the law and order situation, there was reduction in overall trauma cases and the pattern of trauma shifted from penetrating to blunt injuries.

Bone marrow aplasia in Haemophilia-A with Hepatitis-C and human immunodeficiency virus co-infection: A case report.

Haemophilia A is an inherited bleeding disorder caused due to the deficiency of factor VIII. This case report of a 17-year-old HA boy co-infected by hepatitis C (HCV) and human immunodeficiency virus (HIV) followed by bone marrow aplasia seeks to address the key clinical question of the causality and management of bone marrow aplasia in a resource-constrained setting. Our patient developed pancytopenia which prompted the diagnosis and management of HCV and HIV. Bone marrow biopsy revealed severe aplasia. He was treated with highly active antiretroviral therapy (HAART). Two years later, he developed septic arthritis and haemarthrosis of the elbow and knee joints. He underwent arthrotomy of the knee joint. The patient expired, postoperatively, due to septic shock. This case underlines the need for truly universal access to virally inactivated replacement therapy to prevent complications secondary to infections transmitted by transfusion.

First American College of Surgeons National Surgical Quality Improvement Program Report from a Low-Middle-Income Country: A 1-Year Outcome Analysis of Neurosurgical Cases.

BACKGROUND: Low-middle-income countries (LMICs) share a substantial proportion of global surgical complications. This is compounded by the seemingly deficient documentation of postsurgical complications and the lack of a national average for comparison. In this context, the implementation of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) that compares hospital performance based on postsurgical complication data provided by a wide array of centers, could be a major initiative in a resource-challenged setting. Implementation of the NSQIP has provenly mitigated postoperative morbidity and mortality across many centers all over the world. To our knowledge, this report is the first from an LMIC to report its postoperative neurosurgical complications in comparison with international benchmarks. METHODS: Our hospital joined the NSQIP in 2019. Through a standardized ACS protocol, ACS-trained surgical clinical reviewers (SCRs) reviewed and extracted data from randomly assigned neurosurgical patients' medical records from preoperative to postoperative (30-day) data using validated, standardized data definitions. SCRs entered deidentified data in an online Health Insurance Portability and Accountability Act web-based secure platform. The validated data were then consigned to the ACS NSQIP head office in the United States where the data were analyzed and compared with similar data from other centers registered with the NSQIP. In this way, our hospital was rated for each of the variables related to postsurgical complications after both spinal and cranial procedures, and the results were sent back to us in the form of text, tables, and graphs. RESULTS: Our initial report suggested a relatively higher odds ratio for sepsis and readmissions after spinal procedures at our hospital, and a similarly higher odds ratio for morbidity, sepsis, urinary tract infection, and surgical site infection for cranial procedures. For these variables, our hospital fell in the needs improvement category of the NSQIP. For the rest of the variables studied for both spinal and cranial procedures, the hospital fell in the as expected category of the NSQIP. CONCLUSIONS: Implementation of the NSQIP is an important first step in creating a culture of transparency, safety, and quality. This is the first report of NSQIP implementation in an LMIC, and we have shown comparable results to developed countries.

Assessment of Trauma Care Capacity in Karachi, Pakistan: Toward an Integrated Trauma Care System.

BACKGROUND: Pakistan is a lower-middle-income country with a high burden of injuries. Karachi, its most populated city, lacks a trauma care system due to which trauma patients do not receive the required care. We conducted an assessment of the existing facilities for trauma care in Karachi. METHODS: Twenty-two tertiary and secondary hospitals from public and private sectors across Karachi were assessed. The Guidelines for Essential Trauma Care (GETC) tool was used to collect information about the availability of skills, knowledge, and equipment at these facilities. RESULTS: Among tertiary hospitals (n = 7), private sector hospitals had a better median (IQR) score, 90.4 (81.8-93.1), as compared to the public sector hospitals, 44.1 (29.3-75.8). Among secondary hospitals (n = 15), private sector hospitals had a better median (IQR) score, 70.3 (67.8-77.7), as compared to the public sector hospitals, 39.7 (21.9-53.3). DISCUSSION: This study identifies considerable deficiencies in trauma care in Karachi and provides objective data that can guide urgently needed reforms tailored to this city's needs. On a systems level, it delineates the need for a regulatory framework to define trauma care levels and designate selected hospitals across the city accordingly. Using these data, improvement in trauma care systems can be achieved through collaboration and partnership between public and private stakeholders.

Comparative analysis of N95 respirators fit testing with commercially available and in house reagent.

BACKGROUND: Due to COVID-19, thousands of healthcare workers have been affected and have lost their lives in the line of duty. For the protection of healthcare workers, WHO and CDC have made standard guidelines and requirements for PPE use. N95 masks are amongst the most readily used PPE by healthcare professionals and it is highly recommended by OSHA that every make and model of N95 should go through a fit test at least once in a year. METHOD: A total of 30 randomly selected healthcare professionals (who were a regular user of N95 respiratory masks) were subjected to assess in-house (saccharin sodium benzoate) reagent for use for standard qualitative fit testing in our hospital. Threshold testing with the in-house reagent at three different concentrations was performed prior to establish participants' sensitivity to the reagent. After successful completion of threshold testing, fit test was performed on participants wearing an N95 mask. RESULTS: All the participants included in the study passed the sensitivity testing with three concentrations of the reagents, while it was concluded that the concentration of the in-house reagent that was well suited for the sensitivity testing was a concentration of 1g/dl saccharin with 10g/dl sodium benzoate. For fit testing 12g/dl was found to be more appropriate. DISCUSSION: Our study provided a low cost solution to ensure safety of healthcare workers who are regular users of N95 masks following guidelines implemented by OSHA and CDC. CONCLUSION: The in-house test solution prepared was found to be equally sensitive to its commercially available counterpart.

Gastric volvulus in adults in a tertiary care hospital Karachi, Pakistan: A case series.

Gastric volvulus is a rare surgical emergency which is rare in children and occasionally presents in adults. It results due to pathological malrotation of the stomach along its longitudinal or short axis. The condition, if not treated promptly, can result in increased morbidity and carries a high risk of death. Very few cases have been reported in literature regards this important clinical condition. Early decompression and repair of anatomical defects are the corner stone of its management. There is a dire need to develop guidelines and algorithms for management and treatment of this rare condition to improve patient outcome, prevent recurrence and facilitate early diagnosis by practicing physicians and surgeons. We report three such cases which presented to our setup in emergency along with a brief description of how they were successfully managed.

Demonstrating competence in Endoscopic Retrograde Cholangiopancratico graphy (ERCP): Recently credentialed operator's performance for deep biliary cannulation over 1 year period from a tertiary care hospital in Pakistan.

OBJECTIVE: To measure the success rate of endoscopic retrograde cholangiopancreaticography biliary cannulation of a recently credentialed endoscopist at a tertiary hospital. METHODS: The clinical audit was conducted at the Aga Khan University Hospital. Karachi, and comprised data of all patients who underwent endoscopic retrograde cholangiopancreaticography under the care of a single operator during 2016. Data was retrospectively extracted from patient charts by an assistant blinded to the study. Data extracted included demographics, admission type, details and indication for the procedure, diagnosis, cannulation outcome, duct clearance, complications, follow-up surgical intervention, radiological imaging and mortality post-endoscopy. Data was analysed using SPSS 19. RESULTS: Of 143 procedures performed, 102(71.3%) were included. The mean age was 52±17 years and 54(52.9%) of them were females. Most common indication was choledocholithiasis in 70(68.6%). The average procedure time was 41.5±5.5 minutes. Cannulation success rate was 96(94.1%). Complications included post-procedure pancreatitis in 5(4.9%), minimal bleeding in 8(7.8%) and oesophageal perforation in 1(0.98%). There was no procedure-related mortality. CONCLUSIONS: The success rate was high and complications were low with zero mortality.

Impact of a global pandemic on surgical education and training- review, response, and reflection.

The catastrophic effects of the coronavirus disease-2019 global pandemic have revolutionised human society. The unprecedented impact on surgical training needs to be analysed in detail to achieve an understanding of how to deal with similar situations arising in the foreseeable future. The challenges faced by the surgical community initiated with the suspension of clinical activities and elective practice, and included the lack of appropriate personal protective equipment, and the self-isolation of trainees and reassignment to coronavirus patient-care regions. Together, all these elements had deleterious effects on the psychological health of the professionals. Surgical training irrespective of specialty is equally affected globally by the pandemic. However, the global crisis inadvertently has led to a few constructive adaptations in healthcare systems, including the development of tele-clinics, virtual academic sessions and conferences, and increased usage of simulation. The current review article was planned to highlight the impact of corona virus disease on surgical training and institutions' response to the situation in order to continue surgical training, and lessons learnt from the pandemic.

Patterns of traumatic injuries and outcomes to motorcyclists in a developing country: A cross-sectional study.

OBJECTIVE: Motorcyclists are frequently involved in road traffic accidents and may suffer polytraumatic injuries, contributing a substantial burden on healthcare systems particularly in lower-middle-income countries. This study aimed to describe patterns of injury, in-hospital course, and outcomes of road accident trauma in motorcyclists, including polytrauma, at a Trauma Facility in Pakistan. METHODS: A retrospective review was conducted by using relevant trauma codes to extract data from records for all victims presenting with motorcycle trauma between January 2018 and June 2019, to a tertiary care hospital in Pakistan. Data collected included victim characteristics, mechanism of accident, patterns of traumatic injury, management, in-hospital complications, and outcomes. Polytrauma was defined as traumatic injuries in two or more anatomic regions with abbreviated injury scale (AIS) ≥ 3. Multivariable logistic regression, adjusted for age, gender, and mechanism of accident, was performed to identify in-hospital complications and outcomes associated with polytrauma. RESULTS: A total of 514 victims, 90.9% male and 39.5% aged between 18-30 years, were included in this study. The victim was the motorcycle driver in 94.6% of cases. The most common mechanism of accident was motorcycle vs. other motor vehicle (56.2%). Patients were mostly admitted under the services of Orthopedic Surgery (50.8%) and Neurosurgery (30%), with common sites of injury being the lower extremity (42.6%), head (38.1%), and upper extremity (26.8%). Polytrauma occurred in 19.5% of victims. Patients were managed surgically in 77.3% of cases, with the most common procedure being open reduction of fractures (48.1%). Blood transfusion was required in 4.1% of patients. The commonest in-hospital complication was acute kidney injury (23.7%). The median length of stay was 3 days, and 4.1% of patients expired in the hospital. Polytrauma was significantly associated with the need for blood transfusion (2.642 [1.053-6.630]), AKI (2.212 [1.339-3.652]) and hospital length of stay (1.059 [1.025-1.094]), but not with mortality. CONCLUSION: Although orthopedic injuries occur most frequently in motorcycle trauma, polytrauma necessitating multi-disciplinary management and complicating hospital stay is also common. Understanding patterns of injuries and management in motorcycle trauma will enable trauma teams in a developing country like Pakistan to devise evidence-based management protocols, especially for cases of polytrauma.